4:57pm page to the ER for a soft admit?

[ForbiddenComma]

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[benjee]

well, i don't about the system in your facility. Usually, there is a blocked time ( about 30 minutes) right prior to off duty time so to allow the outgoing team organize information and wrap up the rest for sign out . For newly page admission from ER ie few minutes prior to 5 Pm, will take down the information and sign it out to next/incoming team .

 

[TysonCook]

1. We call when we think that the patient needs admitting, NOT based on the time.... The exact same protestations you use for 4:57 can be used by your colleague at 5:03.

2. Your hospital/group should have a written policy on it. Literally, we were told to call even if it was 4:59 and 59 seconds. Reason being is that the groups switched at night, and the profit was set for the admitting group.

3. Before you say "soft admit" in a derogatory way, realize that in community practice the $ comes from the "soft admit", as well as an "easy admit" that doesn't require 20 calls during the night.

4. Lastly, look at the admin emails to the ED docs regarding admissions. Admin ALWAYS want more admits. We literally get several of these noting that if there is even a slight shadow of a doubt, the patient needs to be admitted.

 

[Doctor Bob]

We feel the same way in the department about the phone calls we get from the clinics in a large batch at 5pm saying they're sending a patient over for "a workup".

It works both ways.

 

[anon-y-mouse]

1. We call when we think that the patient needs admitting, NOT based on the time.... The exact same protestations you use for 4:57 can be used by your colleague at 5:03.

2. Your hospital/group should have a written policy on it. Literally, we were told to call even if it was 4:59 and 59 seconds. Reason being is that the groups switched at night, and the profit was set for the admitting group.

3. Before you say "soft admit" in a derogatory way, realize that in community practice the $ comes from the "soft admit", as well as an "easy admit" that doesn't require 20 calls during the night.

4. Lastly, look at the admin emails to the ED docs regarding admissions. Admin ALWAYS want more admits. We literally get several of these noting that if there is even a slight shadow of a doubt, the patient needs to be admitted.

You admit because you feel the patient needs it ("we page when we think the patient needs to be admitted"), yet you also push admissions in order to make money, and because "admin" wants it?? Every single one of those points serves a blatantly selfish motive. Not only are you potentially not doing the patient any good (hello, nosocomial infections for these soft admits and $$$ hospital bills), you want to screw over your colleagues in the hospital (seriously, you can't manage a patient 30 seconds longer while a new service takes over?), but you also want to appease some smarmy "admin" who probably hasn't seen a patient in 20 years. This is why I and many of my colleagues despise the ED.

 

[Law2Doc]

1. We call when we think that the patient needs admitting, NOT based on the time.... The exact same protestations you use for 4:57 can be used by your colleague at 5:03.
...

Maybe some places legitimately ignore the clock, but I have to say I experienced the exact same issues as the OP during intern year. The outgoing ER shift wants to be able to sign out to the incoming shift that they actually did something productive with the long list of patients languishing in the ER all afternoon awaiting lab results. So in the last 20 minutes or so of their shift, they work the paging system, calling consults to admit anyone they don't feel comfortable sending home, even if they've only done a half-arsed work-up at that point.

Which means the IM and surgical teams have to come down, see the patient, write up a consult, talk to an attending and decide whether to admit the patient versus do the EDs job in ordering various labs/imaging that should really be done before a consult is called, all at the time when they are supposed to also be wrapping things up to sign out to their own overnight team. Basically the ED folks who do this screw over the house staff. They aren't practicing medicine, they are moving meat, calling consults because the hour is late, not because the diagnosis indicates a hospital stay. And it IS common practice at many hospitals. There should be policies against clock-based admissions, like benjee suggests, but most hospitals unfortunately don't have them. But don't delude yourself into thinking this isn't happening rampantly and that the folks who do this are behaving professionally rather than cleaning up their own board last minute at the expense of everyone else, so they can tell the next shift "oh yeah, we already called medicine about this one".

So no, the same thing doesn't happen at 5:03 than 4:57. Everyone is happy to get admissions at the beginning of their shift, particularly if they work under a system where they can cap out. But it never works that way because the ED isn't in a rush to clean their board at the beginning of their shift like they are at the end.

As for hospitals wanting more admissions to make more money, I think you have to realize that many of the "soft admits" in the big city are often not paying customers. They are frequently folks looking for a fix or a warm bed which is why they have vague symptoms in the first place. You want a night in the hospital and a few shots of morphine? Say you have a belly pain in the ED at 4:30 and you are set. Additionally, many urban hospitals are so tight on beds that they could be working at full capacity on the legit admits most of the time, and they end up turning "legit" patients away each evening, because they filled up at shift change earlier.

Nobody is begrudging the admissions for acute medical or surgical problems, which ought not wait. But when the dozen or so people who have been sitting in the ED all day suddenly have to be consulted on at 4:57, it's painfully obvious what's going on -- the ED is abusing the other services. And based on the OP and others experience, this is pretty widespread abuse.

 

[VALSALVA]

At least the OP actually did the admit at 4:57 (it's implied) rather than ignore the page, get out of dodge and force the ED to call the oncoming doctor 20 minutes later when the admitting service still hasn't been heard from. Kudos.

 

[Rendar5]

You admit because you feel the patient needs it ("we page when we think the patient needs to be admitted"), yet you also push admissions in order to make money, and because "admin" wants it?? Every single one of those points serves a blatantly selfish motive. Not only are you potentially not doing the patient any good (hello, nosocomial infections for these soft admits and $$$ hospital bills), you want to screw over your colleagues in the hospital (seriously, you can't manage a patient 30 seconds longer while a new service takes over?), but you also want to appease some smarmy "admin" who probably hasn't seen a patient in 20 years. This is why I and many of my colleagues despise the ED.

Just because there is a risk of infection in the hospital, there is also a risk in sending a soft admit home. I realize it's annoying and a pain in the ass when there is a 95% chance that someone is fine (yeah, no chest pain obs unit at my place, 5% is the approximate risk you can knock a chest-painer down with the initial w/u before requiring an admission), but the risk:benefit is still generally in favor of admission for a soft admit.

I also get the lovely job of explaining how my elderly non-specific complaint admits while soft still carry a >50% likelihood of real disease and should not be sent away because the hospital is busy. I'll catch most of the disease process a portion of the time in the ED, but I can't find all processes within the couple hours I have. I understand it's hard to accept this stuff when the majority of the time the resident gains nothing from the experience but more work. But it's more than just CYA medicine from our perspective. Though I guess getting a paycheck for taking admits makes the pill go down smoother than listening to EBM from an EM Res.

Regardless, I really feel for the OP and do my best not to bunch stuff up at the end of their shifts. Same now goes for urgent (non-emergent) surgical consults Thankfully at my institution, my shifts don't coincide with the inpatient staff shifts. If this is an issue at your institute (such as L2D's), you might want to discuss with the higher-ups ways to time it so that inpatient and ED shifts don't coincide. Though I have to make a point that my institute did actually study admission times over the last few years, and despite the fact that residents and I myself find it hard to believe, there are no overall admission boluses, the variability is a function of regular patient, occurring 2-3 hours after peak times. This just happens to mean admissions increase around 2-4pm, and drop off around 10pm-midnight.

 

[ForbiddenComma]

Well, they did it to the night float last night. They got absolutely blown up in the early morning, and half of the admits should have been handled in the ER or as an outpt. You want to see your husband in the morning? Maybe see your kids before they go off to school? No! A 5am constipation x3months is yours instead! The poor girl was on the floor until 9:30am...

I understand ER people are under pressure to admit, due to medicolegal, financial and administration considerations, plus the ever-present desire to free up beds by any means necessary. But this runs up against the very real and very human cost soft admits inflict, especially near shift change. And I don't just mean for the residents. Do you know how much it sucks for the RNs to have an admit hit during signout? Or to get flooded by 8 admits in ~3 hours and have to scramble for floats or prns or anyone they can grab?

I rotate at two hospitals. One place is pretty good at being respectful of resident and RN shift change for non-emergent admissions. The other place, though... the one that I'm at now...

 

[mig26x]

I remember where I trained that the ED resident will page me with "one" admission and when you call he/she tells you: I have two for you. And one time they told me " I have two for you and X resident has another one for you. It didnt help that the majority of the time that this happened was during the ED resident change of "guard" at around 4pm which is the time for IM residents to get screwed with sign out/discharge to facilities/family meetings etc.

 

[Stitch]

Just because there is a risk of infection in the hospital, there is also a risk in sending a soft admit home. I realize it's annoying and a pain in the ass when there is a 95% chance that someone is fine (yeah, no chest pain obs unit at my place, 5% is the approximate risk you can knock a chest-painer down with the initial w/u before requiring an admission), but the risk:benefit is still generally in favor of admission for a soft admit.

I also get the lovely job of explaining how my elderly non-specific complaint admits while soft still carry a >50% likelihood of real disease and should not be sent away because the hospital is busy. I'll catch most of the disease process a portion of the time in the ED, but I can't find all processes within the couple hours I have. I understand it's hard to accept this stuff when the majority of the time the resident gains nothing from the experience but more work. But it's more than just CYA medicine from our perspective. Though I guess getting a paycheck for taking admits makes the pill go down smoother than listening to EBM from an EM Res.

So true.

I've gotten push back for 'soft' admits before, and I tell them that they are welcome to come examine the patient in the ED and send them home after evaluation. Even when the attending is in house, and I KNOW they're close by, I've never had this happen. Strangely, no one else has the balls to send home someone who might be sick and take that liability. Yet I do this every day.

Plus, if they did come and see them then send them home, they couldn't point to the ED during the M&M.

 

[michaelrack]

So true.

I've gotten push back for 'soft' admits before, and I tell them that they are welcome to come examine the patient in the ED and send them home after evaluation. Even when the attending is in house, and I KNOW they're close by, I've never had this happen. Strangely, no one else has the balls to send home someone who might be sick and take that liability. Yet I do this every day.

Plus, if they did come and see them then send them home, they couldn't point to the ED during the M&M.

When I was an IM resident, I would occasionally send home a patient from the ER after discussing the patient by phone with IM. Some of the time the ER demanded that my attending come in before discharging the patient- in these cases some of the time my attending came in and the patient was discharged, other times the patient was admitted. There were a few times I admitted a patient and discharged him from the ward about an hour after admission.

 

[tkim]

One place is pretty good at being respectful of resident and RN shift change for non-emergent admissions. The other place, though... the one that I'm at now...

Try telling the oncoming IM team that you told the ER to hold the next bunch of admits until they're on. That will make you very popular.

 

[Socrates25]

4. Lastly, look at the admin emails to the ED docs regarding admissions. Admin ALWAYS want more admits. We literally get several of these noting that if there is even a slight shadow of a doubt, the patient needs to be admitted.

I beg of you, please send me these emails. I could make a fortune with a whistle-blower lawsuit showing that a patient was admitted for non-medical reasons (i.e. increasing revenues) and then show that the patient was harmed or died because of a non-necessary medical intervention that was done after admission in the hospital.

If I can get the feds to bite so they sue the hospital, I get to recover a sizable percentage of the millions of dollars they are going to settle out of court with.

 

[Buzz Me]

Even when the attending is in house, and I KNOW they're close by, I've never had this happen.

Patients will get admitted without first being seen and examined by the primary team?

 

[Arcan57]

When I was an IM resident, I would occasionally send home a patient from the ER after discussing the patient by phone with IM. Some of the time the ER demanded that my attending come in before discharging the patient- in these cases some of the time my attending came in and the patient was discharged, other times the patient was admitted. There were a few times I admitted a patient and discharged him from the ward about an hour after admission.

In residency, the attending coming in to disposition a patient would happen about once every couple of months. The usual scenario would be a guy with multiple chronic medical problems with moderate metabolic derangements who really needed clinic f/u. The attending would come down, write a note saying dc and they would see them in clinic the next day and everybody was happy. The problem was even with a decent clinic system we couldn't get patients in to be seen in less than a couple of weeks.

 

[anon-y-mouse]

So true.

I've gotten push back for 'soft' admits before, and I tell them that they are welcome to come examine the patient in the ED and send them home after evaluation. Even when the attending is in house, and I KNOW they're close by, I've never had this happen. Strangely, no one else has the balls to send home someone who might be sick and take that liability. Yet I do this every day.

Plus, if they did come and see them then send them home, they couldn't point to the ED during the M&M.

I can think of 3 recent occasions where I have gone down and asked in a plain, deadpan voice, "so, what is the reason for admission?"

Maybe I no longer have a pokerface at 430am, but all those particular times, the ER decided to send the patient home, or at least call the relevant sub-subspecialty service for a quick consult to tell them it as okay to send the patient home to follow up outpatient.

Sometimes forcing people to think on their toes about justifying admission is all it takes.

The worst "soft admit" I had to do was because this demented couple was just essentially demented, and needed to be sent to a nursing home, but had been refusing earlier. The 'admit' was to buy the family enough time to come down and help sort out the social issues. The ER attending was just like "well, where are we going to send them? we can't just send them out of here?" --> why? Unless people are in active danger of hurting themselves/others/spiraling down into further morbidity by leaving the hospital, how can you use the "well, they have nowhere to go" excuse for admission????

 

[Winged Scapula]

Patients will get admitted without first being seen and examined by the primary team?

Happens all the time in community hospitals where the admitting group/physician will just give orders over the phone and either send their midlevel to check it out, or just see the patient the next day. Not that I think its the best plan, but I've seen it frequently (first noticed it in PA, at a community hospital where we did GS with some PP guys. I would see the ED admit patients to medicine with only a phone call to the on call IM group.)

 

[Llenroc]

Good. You deserve to admit that patient. They should get somebody with a whip in the ER to beat you while shouting, "Admit!", "Admit!".

 

[SoCuteMD]

Well, they did it to the night float last night. They got absolutely blown up in the early morning, and half of the admits should have been handled in the ER or as an outpt. You want to see your husband in the morning? Maybe see your kids before they go off to school? No! A 5am constipation x3months is yours instead! The poor girl was on the floor until 9:30am...

I understand ER people are under pressure to admit, due to medicolegal, financial and administration considerations, plus the ever-present desire to free up beds by any means necessary. But this runs up against the very real and very human cost soft admits inflict, especially near shift change. And I don't just mean for the residents. Do you know how much it sucks for the RNs to have an admit hit during signout? Or to get flooded by 8 admits in ~3 hours and have to scramble for floats or prns or anyone they can grab?

I rotate at two hospitals. One place is pretty good at being respectful of resident and RN shift change for non-emergent admissions. The other place, though... the one that I'm at now...

We probably do, as most of us have done at least a few months of floors. Also, it's not as if the ED gets to close down during signout either.

 

[tkim]

Happens all the time in community hospitals where the admitting group/physician will just give orders over the phone and either send their midlevel to check it out, or just see the patient the next day. Not that I think its the best plan, but I've seen it frequently (first noticed it in PA, at a community hospital where we did GS with some PP guys. I would see the ED admit patients to medicine with only a phone call to the on call IM group.)

Happens at the community hospital I work in. 24/7 hospitalists, when they can, come down to the ED to see the pt and write orders, but if they are busy on the floors and the patient has a bed on the same floor, the patient gets sent up without orders.

On the flip side, if the hospitalist wants some further imaging or additionals labs, we'll hold on to the patient while they're drawn and sent or do a drive-by scan on the way up to the floor, since it's easier to get those while in the ED.

 

[gutonc]

Patients will get admitted without first being seen and examined by the primary team?

It does to IM/FM/Peds in our hospital because the ED has admitting privileges to all of those services. Once the "admit trigger" is pulled, they're coming up whether you like it or not. You can certainly go down and examine them in the ED if you want, but since the ED nurses will only follow orders written by ED physicians, there's not much point. To be fair, the workups are generally pretty much done by the time they call and, while there will always be soft admits, the number of "total BS" admits is pretty tiny in my Univ hospital (the VA is another story though).

On my service (Onc/BMT), I will generally go down to the ED to see folks if there's going to be more than 20 or 30 minutes before they come up to the floor. In this patient population, I (and most of my colleagues) almost never debate an admit simply because what looks "kinda sick but OK" one minute can be "kinda intubated on pressors" the next and "kinda dead" shortly thereafter.

 

[Arcan57]

Happens all the time in community hospitals where the admitting group/physician will just give orders over the phone and either send their midlevel to check it out, or just see the patient the next day. Not that I think its the best plan, but I've seen it frequently (first noticed it in PA, at a community hospital where we did GS with some PP guys. I would see the ED admit patients to medicine with only a phone call to the on call IM group.)

Except for really sick surgical patients, the admitting attending almost never sees the patient prior to arrival on the floor at my hospital. In fact, we have 10-15 patients a day that are transferred ED-ED that could easily have been direct admits except that hospital bylaws require direct admits to be seen within 2 hrs of arrival vs. within 24 hrs for ED admits. That and one of our cardiology groups has stopped being willing to admit their OWN patients with CP with
known CAD or straight forward CHF exacerbations.

 

[SoCuteMD]

Happens at the community hospital I work in. 24/7 hospitalists, when they can, come down to the ED to see the pt and write orders, but if they are busy on the floors and the patient has a bed on the same floor, the patient gets sent up without orders.

On the flip side, if the hospitalist wants some further imaging or additionals labs, we'll hold on to the patient while they're drawn and sent or do a drive-by scan on the way up to the floor, since it's easier to get those while in the ED.

Actually, this happens at my residency program for all medicine admissions. Of course, they are seen within less than 24 hours of arrival since the medicine residents are in-house 24/7 unlike community hospitals.

 

[Apollyon]

At the hospital where I am working tonight and the two nights thereafter, I don't even have a hospitalist after 11pm (general medicine patients without an admitting PMD sit in the ED overnight). There are intensivists in hospital 24/7, but I have yet to admit a patient to the ICU via the critical care guys (I am not kidding - just the way it works out; it's open and a combined ICU/CCU). Hell, if there's a DNR that expires on the floor or in the SNF, they call me at night to pronounce them (and I have to pass the upper floor where is the unit, because the broken protocol is that I am "first call" for the pronouncing, with the intensivist second call).

My hospitalists will admit without seeing the patients, but will still give me pushback about admitting them. We don't have residents (did until about 2 years ago), so it's just community. And, let me tell you - there is one hospitalist who has more technical difficulty with her pager than all others I've ever seen - combined. There's this mentality if you are called, but don't answer until after 11pm, you don't have to admit the patient. Not so!

When I was a resident, med students were indoctrinated by surgery and IM (this was at Duke) that the ED sucks. Snobby and snottiness starts early there.

Oh, and, one thing - I don't know of many places where the ED changes at 5pm. See, that's another issue - if I'm out at 3pm or 7pm or 7am, why should I keep track of who changes at 6pm or 6am? IM was not above complaining about that, but ortho was better. I (more than once) asked the ortho guy (as I had not realized they changed at 6am) if I could just call back in 10 minutes, but no one - ever - stopped me after I'd started to talk; however, if I looked at the clock, and just said "oops, wrong call!", sometimes they didn't get it. They realized that what goes around, comes around. If they refuse the 5:58 consult, then they were screwing the guy who comes on in 2 minutes.

And my final thought? Pushback from the hospitalist for a pancytopenic patient from hydroxyurea (with an ANC of 50 - when the hospitalist asked if she was negative from below, I reminded her that DRE was not indicated with neutrophils that low), with the hospitalist saying "I've discharged this patient from the ED before" - 4 days later, the patient was still in the hospital.

 

[anon-y-mouse]

Oh, and, one thing - I don't know of many places where the ED changes at 5pm. See, that's another issue - if I'm out at 3pm or 7pm or 7am, why should I keep track of who changes at 6pm or 6am?

You should keep track of this because you're admitting to the service. It's not like people consult the ER for anything, the ER is realistically a one-way conduit into the hospital. Just like how you have a list of pagers to contact, you are definitely obligated to know something about the service you constantly have to depend upon to "dispo" your patient.

IM was not above complaining about that, but ortho was better. I (more than once) asked the ortho guy (as I had not realized they changed at 6am) if I could just call back in 10 minutes, but no one - ever - stopped me after I'd started to talk; however, if I looked at the clock, and just said "oops, wrong call!", sometimes they didn't get it. They realized that what goes around, comes around. If they refuse the 5:58 consult, then they were screwing the guy who comes on in 2 minutes.

Wait WHAT? How is this screwing the guy coming on in 2 minutes? It's the start of his day when he is at his most fresh, and likely the end of the previous person's 12-24 (maybe 30?) hour shift. Furthermore, you're not saying whether these random ortho people are actually making it down to the ER at 6:10 AM -- more likely they are going to say "bone broken, films done, evaluate" to the next person who comes on at 6am immediately after. Does that really do a service to the following person by being, essentially, an answering machine for ER calls? If anything, it relieves your burden because you can say "service consulted, everything is good to go" to the person coming on after YOU.

And my final thought? Pushback from the hospitalist for a pancytopenic patient from hydroxyurea (with an ANC of 50 - when the hospitalist asked if she was negative from below, I reminded her that DRE was not indicated with neutrophils that low), with the hospitalist saying "I've discharged this patient from the ED before" - 4 days later, the patient was still in the hospital.

What was the patient admitted and treated for? People have low ANC's all the time and live just fine in the outside world on a diet of voriconazole, acyclovir, and moxifloxacin. Fever? Then yes, you have a neutropenic fever and the admission is obviously justified (unless the person is on ATC acetaminophen for a cyclic fever and forgot a dose or something). And, actually, while a digital rectal exam is contraindicated, you do have to pull apart the buttocks and do a thorough superficial exam without introducing a finger, looking for areas of fluctuance/erythema/abscess//cellulitis/blah blah and add coverage for appropriate flora. If a neutropenic patient is coming in with a fever, it is very reasonable to ask what the exam of their bottom is like, since that is a very real source of the fever. Also, the patient staying in the hospital 4 days longer is not intrinsically a justification for anything you said, as so many factors play into that.

 

[tkim]

You should keep track of this because you're admitting to the service. It's not like people consult the ER for anything, the ER is realistically a one-way conduit into the hospital. Just like how you have a list of pagers to contact, you are definitely obligated to know something about the service you constantly have to depend upon to "dispo" your patient.

Wait WHAT? How is this screwing the guy coming on in 2 minutes? It's the start of his day when he is at his most fresh, and likely the end of the previous person's 12-24 (maybe 30?) hour shift. Furthermore, you're not saying whether these random ortho people are actually making it down to the ER at 6:10 AM -- more likely they are going to say "bone broken, films done, evaluate" to the next person who comes on at 6am immediately after. Does that really do a service to the following person by being, essentially, an answering machine for ER calls? If anything, it relieves your burden because you can say "service consulted, everything is good to go" to the person coming on after YOU.

What was the patient admitted and treated for? People have low ANC's all the time and live just fine in the outside world on a diet of voriconazole, acyclovir, and moxifloxacin. Fever? Then yes, you have a neutropenic fever and the admission is obviously justified (unless the person is on ATC acetaminophen for a cyclic fever and forgot a dose or something). And, actually, while a digital rectal exam is contraindicated, you do have to pull apart the buttocks and do a thorough superficial exam without introducing a finger, looking for areas of fluctuance/erythema/abscess//cellulitis/blah blah and add coverage for appropriate flora. If a neutropenic patient is coming in with a fever, it is very reasonable to ask what the exam of their bottom is like, since that is a very real source of the fever. Also, the patient staying in the hospital 4 days longer is not intrinsically a justification for anything you said, as so many factors play into that.

So nice to see the intern lecturing the attending. You'll go far.

 

[Apollyon]

You should keep track...(long interlude)...play into that.

As I said, I'm in the community without residents. When ortho changed was 4+ years ago. Long gone. As for Duke, the resident didn't pass it on to the next person. And, as for "screwing the next guy", you miss the point. You do it to me, I do it to you. That's "screwing the next guy".

As for which service changed when, we couldn't even get an accurate call schedule for Ob/Gyn - month after month, after program director and department chair were involved (on their side and ours), and no reason why - and various other discrepancies. I guess people at Duke "manned up" differently. They got called, they took it. We didn't go out of our way to screw them, even when there was an occasional butt-crack who was the on-call person.

You're paid flat-rate now - maybe, perhaps, your tune will change (or you'll at least see the big picture) when you're in the real world, and out of the ivory tower of academia.

 

[TysonCook]

...Every single one of those points serves a blatantly selfish motive.....but you also want to appease some smarmy "admin" ...

Lets get some things straightened out...

1) You are a resident, when you exit academia, and hit the real world where your group boss (not me) tells you no admits = no pay, you may see things differently. Don't take it from me, ask your admitting friends in private practice. I work on salary, our hospitalists are commissioned, so the emails are from them as well....several of them will see patients even before I consult them.

...and if you go into outpatient medicine, just remember your SDN rant and NEVER send anyone to the ED at 4:57p to get "worked up".

2) Soft admits can go home, as well as come in, we ALL know that there are multiple reasons THAT SHOULD BE DISCUSSED between the ED and admitting service as to WHY the patient can or can't be treated as an outpatient....I'm of the mindset that IF it can be done SAFELY as an outpatient IT SHOULD.

3) It has nothing to do with managing anyone for 30 seconds, as I've noted above WE CALL WHEN WE THINK THE PATIENT WOULD BENEFIT FROM ADMISSION...it's ironic that you're angry about your 4:57 timing, but think that the ED should turn around and base its schedule on yours.

4) At just one hospital I work at we currently have 2 ortho groups that have completely different shift times (which also are different for holiday and weekends), we have appx 4 different IM groups, hospitalist group, and multiple FP groups, cardiology has 2 groups, as well as others. All of which have different schedules.... now mulitply that by however many hospital ED's we staff.

There are literally 100+ different schedules-----My point being do you really think that YOU are the only one who gets the "4:57 call"? Trust me, we get just as many b*tch out calls at 5:03p, as we do at 7:31p, 10:57p, 7:02am, 8:31am, etc.

While I appreciate your resident insight, things will change a little (for the better) when you are finished up.

Socrates25 - Many admits can be done as either outpatient or inpatient...finding medical necessity isn't hard for the vast majority of things, but medicine isn't dichotomous, hence this conversation.

 

[glade]

1. We call when we think that the patient needs admitting, NOT based on the time.... The exact same protestations you use for 4:57 can be used by your colleague at 5:03.

Yeah, THAT'S why everyone can tell when it's shift change time down at the ER and they unload all their patients. Let's hear it for "patient needs"!

 

[Rendar5]

Yeah, THAT'S why everyone can tell when it's shift change time down at the ER and they unload all their patients. Let's hear it for "patient needs"!

yeah, it's not like peak ED times would ever happen to coincide with shift changes, nosir. I mean come on! We all know that most patients come in the middle of the night and in the early morning.

 

[glade]

I'd buy that more if we weren't able to easily discern when these patients arrived at the ER and they've all sat around for hours OR just got there and haven't even been seen but determined to require consultation and were mass dumped. I mean, it's pretty amazing how everyone will arrive at the same "clinical decision" that a consultation is needed at the exact same time ("I have two consults for you and can you hang on, so and so has one and this other guy has two"). Wow, what a coincidence! All the workups and thinking happened to intersect at the same exact second and not just one day ever, but all the time! This is magical!

You gotta love how all the ER people are totally trying to sell this one.

 

[glade]

Oh, yeah, you also have to love how it's like: the busier the ER gets, the smarter their physicians get, apparently. Because they hand out consults WAY faster, so I guess we're to believe that their diagnostic skills and decision making improve ten-fold as the ER fills up, right? I mean, or there's the alternative ...but let's not go there. I'm sure it's all based on patient need after a thoughtful evaluation.

 

[Rendar5]

I'd buy that more if we weren't able to easily discern when these patients arrived at the ER and they've all sat around for hours OR just got there and haven't even been seen but determined to require consultation and were mass dumped. I mean, it's pretty amazing how everyone will arrive at the same "clinical decision" that a consultation is needed at the exact same time ("I have two consults for you and can you hang on, so and so has one and this other guy has two"). Wow, what a coincidence! All the workups and thinking happened to intersect at the same exact second and not just one day ever, but all the time! This is magical!

You gotta love how all the ER people are totally trying to sell this one.

shrug, if you want to disagree with 3 years of my hospital's data on the lack of bolused admission times, be my guest. I only speak for my hospital, but apparently despite not working there you seem to think you know how mine operates.

 

[glade]

Got news for you: if I were able to refuse to see anyone who was inappropriately worked up, meaning:

a) got no vitals, no history, not seen by physician, just got there;
b) got there fifteen hours ago, languished around in a room and then they remembered they were there and now it's urgent that I see the patient immediately because "they're upset they've been here so long"; or
c) it's quittin' time

then my days would be filled with pure boredom and I'd be twiddling my thumbs in the call room.

I'm sure your stats are all nice and everything, but I'm also quite sure that if I were able to do the above your stats would all of a sudden go to pot and everyone at the hospital would be up in arms.

 

[Rendar5]

Got news for you: if I were able to refuse to see anyone who was inappropriately worked up, meaning:

a) got no vitals, no history, not seen by physician, just got there;
b) got there fifteen hours ago, languished around in a room and then they remembered they were there and now it's urgent that I see the patient immediately because "they're upset they've been here so long"; or
c) it's quittin' time

then my days would be filled with pure boredom and I'd be twiddling my thumbs in the call room.

I'm sure your stats are all nice and everything, but I'm also quite sure that if I were able to do the above your stats would all of a sudden go to pot and everyone at the hospital would be up in arms.

please feel free to refuse those cases at my hospital. It won't make a difference in my day.

 

[NateintheED]

Oh, yeah, you also have to love how it's like: the busier the ER gets, the smarter their physicians get, apparently. Because they hand out consults WAY faster, so I guess we're to believe that their diagnostic skills and decision making improve ten-fold as the ER fills up, right? I mean, or there's the alternative ...but let's not go there. I'm sure it's all based on patient need after a thoughtful evaluation.

Contrary to what you all think, it is NOT my job to have a complete workup before I call you. My job is to stabilize life threats, start treatment, and get the patient to where they need to be, and hopefully make a diagnosis in the process.

Having the patient tied up with a nice little bow is a courtesy. And when we get busy, we don't have time to do that. If the patient needs admission, they need admission. There are very few tests I can think of that would change that.

And yes, in big ED's sometimes multiple patients' workups DO become complete at around the same time.

 

[45408]

I really wonder if I just live in a different world where these things don't happen, or if I just care less.


Our ER attendings change shifts at different times than we do, and if something came in at 4:57, the person on call would just take it, because they're the one going to the OR with it anyways.

 

[Law2Doc]

Contrary to what you all think, it is NOT my job to have a complete workup before I call you. My job is to stabilize life threats, start treatment, and get the patient to where they need to be, and hopefully make a diagnosis in the process....

I gotta disagree with you on this. If your job doesn't involve working up patients, then the ED doesn't add much value. In fact, most ED docs would agree that in the ideal world they are absolutely the ones who are supposed to work up the patients and have a pretty good differential diagnosis before they pick up the phone and start dialing consults. THAT is the ED's job -- sorry, but it simply is.

There's nothing wrong with calling a surgeon down because you actually think this guy has a surgical abdomen. But when a guy is there for 4 hours with diffuse abdominal pain, and nobody drew any labs or ordered any imaging, it's inappropriate to decide at 5pm to let the surgeons look at him and decide if it's something surgical. And that's precisely the kind of piss-poor EM medicine a lot of us saw happening during internship, not once, but every day.

Most of the complaints in this thread are precisely because too many folks going into EM today have the same attitude that Nate does, that they are there to stabilize the unstable, and little else. So all too often there are these mass cattle calls at 5pm where they ask the medicine and surgery interns to come down to the ED and start the workup process that really could have been done hours ago, all so they can tell the next shift ("oh, medicine has already been called on this one", as if they actually accomplished something on this patient). That's what folks are complaining about. And yes, that workup absolutely is an EM doctor's job.

 

[tkim]

I gotta disagree with you on this. If your job doesn't involve working up patients, then the ED doesn't add much value. In fact, most ED docs would agree that in the ideal world they are absolutely the ones who are supposed to work up the patients and have a pretty good differential diagnosis before they pick up the phone and start dialing consults. THAT is the ED's job -- sorry, but it simply is.

So, that's my job in the 'ideal world'. What's my job in the real world? Two vented ICU players being boarded, a couple of tele admits hanging out, wait times of 4+ hours for the undifferetiated waiting room masses. Being passed EKGs to look at every 30 mins, while trying to get some primary to call back on a weeked night. I'm not complaining - that's what I signed up to do. But it's rich that you would deign to tell me what my job is. Thanks.

There's nothing wrong with calling a surgeon down because you actually think this guy has a surgical abdomen. But when a guy is there for 4 hours with diffuse abdominal pain, and nobody drew any labs or ordered any imaging, it's inappropriate to decide at 5pm to let the surgeons look at him and decide if it's something surgical. And that's precisely the kind of piss-poor EM medicine a lot of us saw happening during internship, not once, but every day.

Dunno where you're training, but calling surgery without labs +/- imaging for a fishing expedition where I trained is grounds for yelled at twice - by our attending and the surgical attending. Name you place.

Most of the complaints in this thread are precisely because too many folks going into EM today have the same attitude that Nate does, that they are there to stabilize the unstable, and little else. So all too often there are these mass cattle calls at 5pm where they ask the medicine and surgery interns to come down to the ED and start the workup process that really could have been done hours ago, all so they can tell the next shift ("oh, medicine has already been called on this one", as if they actually accomplished something on this patient). That's what folks are complaining about. And yes, that workup absolutely is an EM doctor's job.

Of course, you conveniently leave out the other parts of Nate's line - you know, the part about "... start treatment, and get the patient to where they need to be, and hopefully make a diagnosis in the process." But I guess that would make your post look petty.

Contrary to what non-EM think, the ER doc's job is *not* diagnosis, but exclusion. Completely different mind-set, and hard to adjust to unless you been trained to think that way. Diagnosis happens a lot, but it's exclusion of badness that's really the goal. "Not PE." "Not CVA." "Not MI." "Not appy." Less concerned about anxiety-induced tachycardia, early Bell's palsy, costochondritis, or gastroenteritis, but gotta rule out the badness before I label you with the other dx.

But that's life in the fishbowl. Everyone has to take a jab at ER.

 

[Rendar5]

Just out of curiousity, to everyone complaining, your ED resident shifts actually end around 5pm? It's weird cause I don't know any places in NY that do that. Are they 8 or 10 hour shifts or something?

 

[45408]

THAT is the ED's job -- sorry, but it simply is.

.....

And yes, that workup absolutely is an EM doctor's job.

Based on whose guidelines? Serious question.

 

[Law2Doc]

...
Dunno where you're training, but calling surgery without labs +/- imaging for a fishing expedition where I trained is grounds for yelled at twice - by our attending and the surgical attending. Name you place.
...

I won't name my place and it's inappropriate to ask on an anonymous board, for numerous obvious reasons.

But if you just read through this thread, you will see that this is apparently a very common complaint. I was actually surprised to see how common this was -- I had chalked it up to simply the one ED I have experience with, but I see it's more epidemic.

That's great and appropriate that you would get yelled at for doing this, but unfortunately there are plenty of your EM brethren who are giving your field a bad rep, and assuming more of a "moving meat" role rather than actually adding doctoring value, particular at the end of shift changes. Just look through the thread and you will see that this is a complaint way too many people at different places are having. More than a few of us have gone down to the ED, only to have to write orders for imaging and labs that should have been the deciding factor as to whether a consult got called in the first place, precisely because the ED doc wanted to sign out that he had "finished with" the patient.

 

[Law2Doc]

Based on whose guidelines? Serious question.

Every hospital department has it's own protocols, which may or may not apply here. But it's more of a commonly understood role here -- the ED serves a triage function for the hospital. The ED is the decision point as to whether a consult is needed. So it's taken for granted that they first do the basic tests and imaging necessary to determine whether a patient should be sent home or go up to the wards. It is not appropriate to call a consult before you run those basic tests, unless eg it is clinically obvious that the patient needs emergency surgery, etc. So the ED shouldn't call ortho for "arm pain" without getting an X-ray, and they should not call medicine or surgery for diffuse abdominal pain without some labwork to determine if the patient has pancreatitis, or imaging to determine whether this is a surgical problem, or maybe just indigestion. Once they do the basic tests, then they can decide whether this is a patient who goes up to the wards or gets kicked to the curb. To do otherwise is precisely calling a consult to do a "fishing expedition" as tkim aptly calls it. Which is inappropriate. The ED is set up to triage and decide who goes up to the floor and who doesn't. To pass this task on to the house staff because the shift is coming to an end is inappropriate. And unfortunately more widespread than some of the EM docs on here are willing to accept.

 

[Rendar5]

Every hospital department has it's own protocols, which may or may not apply here. But it's more of a commonly understood role here -- the ED serves a triage function for the hospital. The ED is the decision point as to whether a consult is needed. So it's taken for granted that they first do the basic tests and imaging necessary to determine whether a patient should be sent home or go up to the wards. It is not appropriate to call a consult before you run those basic tests, unless eg it is clinically obvious that the patient needs emergency surgery, etc. So the ED shouldn't call ortho for "arm pain" without getting an X-ray, and they should not call medicine or surgery for diffuse abdominal pain without some labwork to determine if the patient has pancreatitis, or imaging to determine whether this is a surgical problem, or maybe just indigestion. Once they do the basic tests, then they can decide whether this is a patient who goes up to the wards or gets kicked to the curb. To do otherwise is precisely calling a consult to do a "fishing expedition" as tkim aptly calls it. Which is inappropriate. The ED is set up to triage and decide who goes up to the floor and who doesn't. To pass this task on to the house staff because the shift is coming to an end is inappropriate. And unfortunately more widespread than some of the EM docs on here are willing to accept.

Well, as I've said, I've seen accusations of bolusing at my own institution, data that shows the accusations simply aren't true, and residents preferring their own biases to actual data.. especially when the majority of shift changes in my ED occur at around 7, 10, and midnight. So whether or not these complaints are diffuse and generalizable, I've got nothing to go on but my own experience. which if you generalize it out, says that complaints tend to be more based on perception than fact (kinda similar to all complaints that occur in healthcare).

 

[tkim]

That's great and appropriate that you would get yelled at for doing this, but unfortunately there are plenty of your EM brethren who are giving your field a bad rep, and assuming more of a "moving meat" role rather than actually adding doctoring value, particular at the end of shift changes. Just look through the thread and you will see that this is a complaint way too many people at different places are having. More than a few of us have gone down to the ED, only to have to write orders for imaging and labs that should have been the deciding factor as to whether a consult got called in the first place, precisely because the ED doc wanted to sign out that he had "finished with" the patient.

Where I work now, there is no massive shift change where all the ED docs sign out to the oncoming shift, we're staggered. Patients with pending dispos, i.e., lab, imaging results, treatment responses, are signed out to the oncoming doc, and consults called appropriately.

But aside from the 7A, 7P massive signout, there's no difference in what I did in training, and what I do now.

I will say, however, that during residency, if we're about to sign out a patient that is heading towards a consult, the first person to see that patient is obligated to call the consult, since that person has first contact, and has spent more time doing the workup, and essentially, driving the dispo.

Perhaps it's that obligation we feel to call for a consult before we sign out, even if the dispo is at that point, unclear, is the major difference between residency and private practice. And the reason why it seems as if more consults are called around shift change. Yes, in some twisted, ER way, we feel obligated to call the consult because we're first person who saw them. Silly us.

You want to hear about variability, how about old versus new surgeons. It's a toss of the coin when I call a surgeon and they either ask me why I waited so long to call, why I did or didn't do X Y Z test or image before calling, or why I called at all. The last thing is usually to call for a medicine consult to manage some medical problem - HTN, DM - you know - **** you can't treat with a dose of Vanco/Zosyn or cut out with a knife.

Old school surgeons, they tell me not to order any tests, and press hard on some part of the belly, and see if the patient screams. New surgeons, they ask me what the CRP, WBC, INR are, and what the results of the CT scan are, and whether I can admit to/consult medicine for comorbidities, before they come down.

 

[Buzz Me]

While I will readily admit that we have some great EM attendings and residents who call for very appropriate consults, it's the other calls (the majority, unfortunately) that hurt us and leave a bad taste in our mouths.

*Patients who have been sitting down in the ER for 8-16 hours with little to no workup, and often only 1-2 sets of vitals
*Patients with "surgical abdomens" who just have abdominal tenderness
*Patients without labs or imaging (often just got wheeled in from triage with a chief complaint of abdominal pain)
*Patients who are just sick and need someone, anyone, to quickly come downstairs to help out (knowing that Gen Surg residents tend to come see consults quickly)
*I also tend to agree that we get bombarded with consults at 7 am, 7 pm and 11 pm...change of shift time. I've heard EM residents talk about how they do that because when they "run the board" at these times, it's poor form to have no pending dispo on a large bulk of patients. I also did an ER rotation as an intern, so I know how this goes.
*What's also frustrating is when you get the change of shift consult, and by the time you get down to the ER (5-10 minutes later) that original ER resident who called you has gone home, and their replacement has a very inadequate signout...and often he/she hasn't even seen the patient yet. Not that this is exclusive to EM...Medicine does this all the time too (when their post-call intern calls for a consult, but then you go see the patient and the cross-cover doesn't know anything and can't communicate with you).

I understand that at many hospitals, SBOs, abdominal pain r/o appy (with contraindication to CT), etc. have to get admitted to Gen Surg. But we get frustrated because of all those consults/admissions, we might actually operate on 10% of them. So the vast majority indeed do NOT have a surgical problem.

Again, there are very reasonable folks downstairs who always do a great job and with whom I have no problems. But it's those other ones...

Agreed that for many, observational bias over a few months of consults may skew their perceptions. But I've been doing this for quite a few years now, and have sadly seen the same behavior time and time again (at multiple hospitals, but mainly at one in particular). What's equally sad, for that matter, is that those M3s that I used to see helping out when I was an intern on ER are now ATTENDINGS!

 

[Apollyon]

Yeah, a few posts on SDN are "a very common complaint". Set the bar low.

However, to anyone who is reading, I'll tell you outright (with no concern for "obvious reasons" - which mostly are not, save one - and no real reason why it is inappropriate - not so, to ask: one may refuse, and that is it - there is no reason to argue it out, irrespective of the adversarial nature of it) that I was a resident at Duke.

We were asked, when I was there, by the chairman of IM and the program director, to not do such complete workups - that we were sending patients upstairs with nothing to do for the admitting residents except to write notes. When there was no EM program, the IM residents did the leg work. When EM came round, most of the work happened in the ED. If I have your ceruloplasmin level (I Am Not Making This Up) and MRI report with a finding that the fellow quoted that which none of 3 senior residents had ever heard or were familiar, there's not a lot left.

It's easy in the retrospectoscope to MF the ED - you all go and get up on yourselves! Go you! If there is something that wasn't evident after a rather exhaustive workup, which you located on HD #2 or #3, well, it's OBVIOUS that we missed it in the ED.

I mean, brilliant residents OBVIOUSLY have grounds to bring this to their program directors and chairs - your education is being stilted, delayed, diminished, and halted due to "inappropriate consults" - OBVIOUSLY, these detract from "real" cases - which, coincidentally, come in as the same calls you get for the "inappropriate" ones. Your differentiating - as the specialist - which one is "real" and which one is "appropriate" is why you are being called - you're the specialist. That is the job for which you are training. How many of you are making the call as junior residents that a case is "bogus" without talking to someone? Are you that gutsy? As I learned in military school (but not to offend the wilting lilies): "There's a fine line between (synonym for "guts") and stupidity".

 

[Law2Doc]

...
I will say, however, that during residency, if we're about to sign out a patient that is heading towards a consult, the first person to see that patient is obligated to call the consult, since that person has first contact, and has spent more time doing the workup, and essentially, driving the dispo.

Perhaps it's that obligation we feel to call for a consult before we sign out, even if the dispo is at that point, unclear, is the major difference between residency and private practice. And the reason why it seems as if more consults are called around shift change. Yes, in some twisted, ER way, we feel obligated to call the consult because we're first person who saw them. Silly us....

And that is a fine system IF that initial person has in fact "spent more time doing the workup". What we are complaining about is the rampant calling of consults BEFORE any workup is done, simply because they feel this obligation to say they have called a consult before they sign out. It's just bad ED medicine and it's happening at quite a few places at 5pm (or whatever sign out time various EDs use at various places). And it screws up the house staff big time because at the time they too are supposed to be wrapping things up to sign out themselves, they have to go down to the ED both to do a consult AND to order all these workup tests that should really be done before a consult is called. That's what everyone on this thread is complaining about.

Great that it isn't happening in your ED, but no so great that it is happening in quite a few others and tarnishing EMs rep generally. So those of you doing it the right way really ought to put pressure on your national organizations and at your national meetings and get the rest in line, or live with an undeserved bad rep.

 

[Cerberus]

Just out of curiousity, to everyone complaining, your ED resident shifts actually end around 5pm? It's weird cause I don't know any places in NY that do that. Are they 8 or 10 hour shifts or something?

I've not been anywhere where ED docs finish at 5pm. Every ED I've worked in (N=4) the shifts have ended at 7pm/am, 11pm, 3pm, or 1am. Still, I've yet to see any of these places bolus dispos. I honestly could give a damn whether your shift is about to end. It doesn't matter to the pt that is being resusc'ed when my shift is ending, I don't whine about it, I just man up and do my job. Luckily the medicine people at my institution rarely whine about doing their jobs, they just do it.